MIS THESIS

THE SUFFOLK COUNTY MEDICAID
PHARMACY MANAGEMENT INFORMATION SUBSYSTEM
By
Michael J. Lubrano, Jr.

A thesis presented to the faculty of the Graduate School of Health Care and Public Administration, Long Island University, in partial fullfillment of the requirements for the degree of Master of Public Administration.

Department of Health Care and Public Administration
C. W. Post Center
Long Island University
Greenvale, NY 11548

May, 1981

[Back to Top] [INTRODUCTION] [Conclusion] [ENDNOTES] [End of Thesis]

TABLE OF CONTENTS

        INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  1

        Chapter
            I. THE OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . .  4

                    Medical Assistance Goals
                    Management Information System Concepts

           II. BACKGROUND INFORMATION . . . . . . . . . . . . . . . 12

                    The Manual System
                    Program Alternatives

          III. DEVELOPMENT OF THE PMIS . . . . . . . . . . . . . . . . 29

                    The Model System
                    The New Design
                    The Reporting System

           IV. A SECOND ANALYSIS . . . . . . . . . . . . . . . . . . . . . . . . 40
                    Governmental Behavior
                    PMIS Behavioral Analysis
                    Conclusion

        . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

        APPENDIX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

        ENDNOTES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

        BIBLIOGRAPHY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68

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INTRODUCTION

      By December 1975, the Suffolk County unemployment rate reached 9.7 percent. There were over 18,000 public assistance cases; up 3,300 cases or 22.4 percent from December 1974. This represented 57,300 adults and children on public assistance. The total eligible Medicaid population, which includes both public assistance and non-public assistance cases, increased from 72,847 in December 1974 to 80,485 in December 1975; an increase of over 7,600 cases or 10.5 percent. ¹

      The 1976 Suffolk County Budget of $535 million could not by itself have supported the $201 million or 38 percent to be spent by Social Services. ²   Since Medicaid expenditures alone represented $89.1 million in 1976, a major effort had to directed toward cost containment procedures for medical assistance. ³   Although the reimbursement varies between programs, on the average Suffolk County receives fifty percent Federal and twenty-five percent State aid. ⁴   Even though the majority of this money is transferred back into the local economy through recipient purchases and medical bills paid by Medicaid, the locality is still mandated to spend more than it receives in transfer payments. The local taxpayers must therefore, both directly and indirectly carry this tax burden. The fact that there is a multiplier effect working to benefit the local economy was of little consolation and Suffolk County realized that some very serious consideration would have to be given toward the containment of Medicaid expenditures. ⁵

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      In addition to these fiscal problems, the Suffolk County Medicaid program was also faced by a continual increase in the number of claims submitted for Medicaid services. It was therefore hoped that the automated Monroe County Model Medicaid System could be used in Suffolk County to handle the growing claims volume. Although most of the medical and dental services would continue to require manual review in the model system, it was believed that the automated drug price file could be used to process the majority of drug claims. Since drug claims represented nearly half the total Medicaid claims volume, and drug expenditures increased by eleven percent in 1974 to $3.5 million, it was hoped that the Model System would offer some much needed relief for the strain being placed upon the manual pharmacy system which existed at that time. ⁶
      The primary question facing the Medical Assistance Pharmacy Unit was whether or not it would be possible to implement and maintain an effective automated pharmacy program at the local county government level. This study will therefore be concerned primarily with the development of the current pharmacy management information subsystem. It will try to show that the current program fulfills both the objectives of a Management Information System (MIS) and the objectives of the Suffolk County Medical Assistance Administration (MAA) by emphasizing the influence the system has had upon: (1) cost containment, (2) claims processing, and (3) the availability of program information.
      The beginning chapter will present overall objectives and will be divided into two main sections. The first section will present the goals and legal mandates governing the medical assistance program. The second section of the chapter will be concerned with the definitions and concepts of management information systems.
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CHAPTER I

THE OBJECTIVES

Medical Assistance Goals

Legal Basis and Enabling Legislation

      The Suffolk County Department of Social Services was created under the County Charter and the New York State Social Services Law. The Department must function within the guidelines of the Federal Social Security Act of 1935 and its amendments. It also comes under the jurisdiction of the United States Department of Health and Human Services, and the New York State Department of Social Services. ¹

      Within the Department of Social Services, the Medicaid Program is designed to provide comprehensive health care for needy persons who are unable to purchase such care for themselves. The Medical Assistance (MA) Division functions pursuant to Title XIX of the Social Security Act; Title XVIII of the New York Codes, Rules and Regulations, Section 515; the New York State Medical Handbook; and the Medical Assistance Contract with the New York State Department of Health. ²

      Combined, these laws define the Medicaid Program's scope of services and eligible population. Since failure to follow these regulations would result in the loss of Federal and State reimbursement to the County, it can readily be seen how important it is to adhere to these mandates so that maximum reimbursement can be obtained. The use of federal and state funding requires these programs to be implemented in conformity with the original guidelines. The possibility of a reduction in the reimbursement rate or the application of penalty charges is used as a lever to assure such conformity, especially since these programs would not be possible without the larger tax resources of the federal and state governments. Local districts may not propose alternatives to minimize the cost of medical care by simply writing new policy, since it is not possible at the local level to reduce either the program's scope of service or the groups eligible for participation. Changes of this nature require either federal or state enabling legislation and adjustments in the state plan. ³

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Program Goals
      In Suffolk County, both social and health aspects of the New York State Program of Medical Assistance for Needy Persons, more commonly called the Medical Assistance (Medicaid) Program, are joined in one Medical Assistance Administration (MAA). This Medical Assistance Administration is charged with the responsibility to interpret and implement the laws, regulations and policies mentioned in the preceding section. MAA is therefore responsible for seeing that appropriate high quality health care is available to Medicaid eligible persons at the lowest possible cost and with a minimum of administrative delay. ⁴

      The Quality Utilization Review (QUR) section of MAA is specifically responsible for reviewing the quality of medical care and monitoring reimbursements. It must also take full advantage of cost containment procedures to help alleviate he financial burden of these mandated services. Within QUR, the pharmacy unit reviews pharmaceutical services supplied to non-institutionalized Medicaid clients and monitors reimbursements for these services. ⁵

      The Pharmacy unit is responsible for the supervision and coordination of the manual review and system maintenance procedures of pharmacy claims. It participates in setting local policies and procedures, monitors services, prepares notices, and reports on all pharmacy activities. This unit acts as liaison with pharmacy providers, other health care providers, professional organizations, public officials, Medicaid clients and the general public. In order to fulfill these responsibilities, the pharmacy unit requires program information for its decision-making functions. The following section of this chapter will therefore be devoted to describing how and why the MIS concept was developed to fulfill this need.

Management Information System Concepts
      Leon K. Albrecht defines a business information system as "one that captures, gathers, classifies, manipulates, and disseminates business information." ⁶   Joel E. Ross, however, states that:
      A system can be described simply as a set of elements joined together for a common objective. A system is part of a larger system with which we are concerned. All systems are parts of larger systems. For our purposes the organization is the system and the parts (divisions, departments, functions, units, etc.) are the subsystems.       ... The systems concept of MIS is therefore one of optimizing the output of the organization by connecting the operating subsystems through the medium of information exchange.
        The objective of an MIS is to provide information for decision making on planning, initiating, organizing, and controlling the operations of the subsystems of the firm and to provide a synergistic organization in the process. ...
        ... "a management information system" ... provides information for planning, actvates plans, and provides the essential feedback information necessary to achieve stability through the control process. ...
        ... This component (MIS) collects, analyzes, stores, and displays data to management decision makers at all levels for the management of the resource flows of materials, manpower, money, and facilities and machines. ⁷
      E. W. Martin, Jr. and William C. Perkins define a system as "an assemblage or combination of things or parts forming a unitary whole" and believe that one of the most important characteristics of systems is that they may be considered to be composed of hierarchies of subsystems.  "Calling something a system does not change it, but it does express a point of view toward the thing, and this point of view frequently provides a powerful framework for analysis."  A MIS is therefore an organization's system "to efficiently provide the required information to the proper managers at the time it is needed to plan, operate, and control the organization for optimum performance." ⁸

      Beginning with the definition of the word data, Donald H. Sanders says that:
        The word data is the plural of datum, which means fact. Data, then, are facts, unevaluated messages, or informational raw materials, but they are not information except in a constricted and detailed sense. ...
        As used in this text, the term information is generally considered to designate data arranged in ordered and useful form. Thus, management information will usually be thought of as relevant knowledge, produced as output of processing operations, and acquired to provide insight in order to (1) achieve specific purposes or (2) enhance understanding. ... The products produced by the manufacturing process have little utility until they are properly applied; similarly, the information produced by data processing is of little value unless it supports meaningful decisions leading to appropriate business actions. The purpose of data processing is to evaluate and bring order to data and place them in proper perspective so that meaningful information will be produced. ...
        ... A procedure is a related group of data processing steps or methods (usually involving a number of people in one or more departments) which have been established to perform a recurring processing operation. ... management information systems are networks of data processing procedures developed in the organization, and integrated as necessary, for the purpose of providing managers with timely and effective decision-making information. ⁹
      Jerome Kanter prefers to stress the management aspects of management information system. Although he recognizes the definition of management as getting things done through people, Kanter states that he prefers the more definitive interpretation of management as "the planning and control of the physical and personnel resources of the company in order to reach company objectives."  Therefore, a MIS is a system that "aids management in making, carrying out, and controlling decisions." ¹⁰

      According to Donald F. Heany, "a system is generally defined as an assemblage of independent, interrelated entities," and an information system is:
        ... a set of well-defined rules, practices, and procedures by which men, equipment, or both are to operate on given input so as to generate information satisfying specifications derived from the needs of given individuals in a given business situation. ...
        ... Specifications about what input is to be used, how it is to be arranged on input media, the sequence in which it is to be manipulated, and the way results are to be displayed are all critical features of the definition of an information system.
If the rules, practices, and procedures for handling input are carefully spelled out, and if the output satisfies the posed information requirement, then a formal system exists, whether it is a manual information system in which human processors carry out the operations on input or a computer-based information system designed around electronic processors. ¹¹

      Martin and Perkins stress the utilization of computers as follows:
        ... Computerized management information systems accept information concerning every activity that affects the organization; they summarize and store this information and relate it to past history and to current plans; they use this information to make the routine decisions that computers can make; and they present to each manager the pertinent, digested information that he needs to perform his planning, controlling, and decision-making duties. In addition, the manager can interrogate the system to obtain additional information whenever he needs it. ...
However, they also stipulate that:
        ... no company has a completely integrated management information system ... but literally hundreds of companies are in various stages of development of such systems. ...
Computers have, in general, been quite successful in reducing the unit costs of processing, and can efficiently handle volumes of processing that would be almost impossible to cope with by manual methods. In addition, the major potential benefit of computers is not just doing what clerks can do, but also in producing information for management that could not otherwise be obtained. ¹²

      Heany, however, believes that manual systems:
        ... are preferred to computer-based systems, in some situations, such as when criteria for decision making are not well defined, when volume of data to be processed is small, and when the rules for making decisions change frequently. The manual systems may also be superior where the quality of data entering the system is erratic and standards of consistency cannot be maintained. Manual systems are also attractive when processing steps are few and difficult to routinize, and when the cost of developing, operating, and maintaining the system is modest by contrast with a computer-based
system. ¹³
      Computers are viewed as only one of the many tools at management's disposal by Ross who states:
        Despite the fact that the computer is nothing more than a tool for processing data, many managers view it as the central element in an information system. This attitude tends to overrate and distort the role of the computer. Its real role is to provide information for decisions and for planning and controlling operations. ...
        MIS is not new; only its computerization is new. Before computers, MIS techniques existed to supply managers with the information that would permit them to plan and control operations. The computer has added one or more dimensions, such as speed, accuracy, and increased volumes of data, that permit the consideration of more alternatives in a decision. ¹⁴
      Now that the reader has been armed with the objectives presented in this chapter, the author will devote Chapter II to describing the original manual pharmacy system and the possible alternatives that were reviewed and evaluated.

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CHAPTER II

BACKGROUND INFORMATION

The Manual System
      Prior to 1976, the only available statistics on Medicaid drug expenditures were the total dollars paid and an estimate of the total number of drug claims paid. The system was very primitive by today's standards and only about ten percent of the claims processed were ever reviewed or checked for accuracy.

      Two pharmacists and from four to six clerical workers would review drug claims and validate the prices being charged by the pharmacy providers. Following winter cold and flu seasons, there would be an increase in the number of claims received so that only every fifteenth claim would be reviewed. During slack seasons, the reviews could be increased to every fifth claim. Since the claims were not processed in ant specific order, reviewers were continually shuffling the claims to choose those that would require the least effort for price verification and review. One major exception to this procedure was that all clams for drugs priced over twenty dollars would be held for review by one of the pharmacists. These higher priced prescriptions were thereby subjected to additional processing delays.

      At the end of each work day, the prescription claims processed by each reviewer would be stacked and measured with a ruler to estimate the number of claims being paid. Since each claim could contain either one or two prescriptions, the estimates for the total number of prescription services was subject to even greater error. The need for better control, as well as, the threat that annual audits would result in penalty reductions of Federal and State aid to Suffolk County, therefore prompted the Medical Assistance Administration to investigate what alternatives would be possible. ¹

      If MAA was going to continue to administer a Medicaid Drug Program, then a system would be needed which could:
      1) verify pricing on all claims processed,
      2) process payable claims and reject non-payable claims,
      3) expedite payments to providers for payable claims so that
          payments could be made on a more timely basis,
      4) collect, store, process, and make accessible the necessary
          information for reporting and control functions, and
      5) allow maximum utilization of cost containment measures.

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      The following sections will present eight possible alternatives. The alternatives will be described, compared, and evaluated so that the anticipated results of using one or more of these alternatives can be forecast. The first four alternatives mentioned concern transferring, limiting, or discontinuing services, whereas the remaining four alternatives will discuss variations in delivery and review methods.

Alternative One: Transfer to the State
      Transferring the entire Social Services Program, including all Medicaid expenditures, back to the State level would reduce the local property tax burden. However, an in-depth analysis of this alternative would be beyond the scope of this study for two reasons:
(1) the County Executives of New York State localities have, so far, managed to provoke only minor initial stirrings at the State legislative level concerning this proposal, and
(2) this alternative would not effect any actual reduction of expenditures since it only shifts the burden onto the Federal and State tax structure.
      According to Lee and Johnson:
        A final suggestion for relieving both states and localities of some of their financial burdens involves shifting total responsibility for major functions to a higher level of government.⁴³  Most frequently advanced are proposals that education be taken over entirely by the states and welfare by the federal government. Such proposals provide an obvious form of financial relief, especially for local jurisdictions. Their principal weakness, however, is that they still do not face squarely the problem of interarea fiscal differences and whether it should be national policy to eliminate those differences.
______
    ⁴³  See Advisory Commission on Intergovernmental Relations, Pragmatic Federalism: The Reassignment of Functional Responsibility (Washington: U.S. Government Printing Office, 1976). ²

      They summarize the problem of overlapping taxes by writing that:

... Basically, the problem is that the sum of all governmental tax resources is the nation as a whole, even though governments vary as to what portions of that whole are taxed. Therefore, no matter what particular forms of taxation are used by the different levels of government, the same people and firms will be affected. ³

      Advantages from the economy of scale are also addressed when they state that an:

        ... advantage of multiple governments is that economies of scale may be achieved; that is, functions may be performed by the sized unit that is most capable of performing them. Just as it is may be advantageous from the standpoint of efficient resource utilization for private, profit-oriented organizations to grow to a large scale, it may also be more efficient to conduct some governmental activities on a large scale by one unit of government. The defense of the nation is ore economical when conducted by the federal government then it would be if each state were assigned the responsibility of defending its own territory. On the other hand, to perform all governmental functions at the central level might result in inefficient conduct of some activities. Lessened flexibility of operations and other diseconomies suggest the need for some functions to be performed by units of government smaller than the federal government. Probably many services can be provided most efficiently at the local level. ³
_____
    ³Due and Friedlander, Government Finance, p. 487. ⁴

      Actually, in 1976, the State Department of Social Service would not have been able to run the entire program. New York counties functioned as fiscal intermediaries under a single state plan and independent health care providers supplied medical care. No state system existed at that time and no one could demonstrate that there would be any advantage, such as from the economy of scales, to a state take over of the local programs. Robert Heller even goes as far as to attack the notion of economy of scales by saying that, "The finest economy of scale, from the executive's point of view, is that size can bury monumental mistakes." ⁵

Alternative Two: Eliminate Drug Services
      Since drugs are one of the optional services included in the New York State Plan, the possibility of recommending that drugs be deleted was also investigated. In Suffolk County, drug expenditures increased from 3.1 million dollars in 1973 to over 5.4 million dollars in 1976. ⁶
      Although these figures represent only about six percent of the Medical Assistance expenditures, pharmacy claims accounted fro nearly fifty percent of the claims volume. ⁷
      Even though the thought of cutting the claims volume in half and reducing expenditures by over five million dollars seems attractive, it would be unlikely for drugs to be eliminated for three main reasons.
      First, if Suffolk County was to unilaterally eliminate the drug program, it would be in violation of the New York State Plan and therefore, subject to a penalty in the form of the loss of Federal and State Funding.
      Second, drug services are utilized by a majority of Medicaid clients and there would be a sizeable amount of political disfavor generated at both the state and county levels if the drug program was discontinued. As Thomas P. Lauth wrote:     ... Budget officers contend that public expectations preclude the reconsideration of the historic base each year. Certain functions of government, they believe, are simply not going to be significantly reduced (much less eliminated) for reasons of economic efficiency no matter how compelling the data and analysis. The level of public sector responsibility for ameliorating social problems and providing social amenities has evolved over many decades. The political costs of breaking faith with citizens on matters which are thought to have been resolved in the past are very high. ⁸

      Third, the impact of this decision could very likely increase rather than decrease the overall Medicaid Program expenditures. One of the most important functions rendered by the drug program stems from the fact that it is a vital part of primary and ambulatory care. Patient self-care, as well as care supplied by the patient's family, helps to prevent and/or reduce the need for more expensive institutional care. The drug program, in conjunction with other ambulatory services like home health aids and medical equipment, is an integral service which allows the movement of patients out of the more costly service of hospitals, nursing homes, and institutionalized psychiatric and rehabilitative settings. According to the firestone indexes, between 1967 and 1975, although prices on consumer items increased by 70.5 percent and prices on medical care costs increased by 94.7 percent, prescription drug prices increased by only 16.9 percent. ⁹

      Since over sixty-five percent of the total dollar expenditures are spent for services in chronic care facilities and hospitals which have state mandated service rates, the main option presently available for the County to reduce these expenditures is by moving patients out of institutionalized settings as soon as possible and fostering programs for self-care. It can also be argued that good primary health care will prevent future unnecessary, as well as excessively long, institutional stays. Since the Suffolk County Medicaid Program has an overall goal of cost containment for medical expenditures, th greatest efforts should be turned toward decreasing institutional services through the more efficient use of primary care. This alternative, to eliminate the drug program, would therefore be counterproductive. ¹⁰

Alternative Three: Develop a Generic Drug Formulary
      On February 6, 1977, Legislator Robert Mrazek (D-Centerport), Chairman of the Legislative Finance Committee submitted the following resolution to the Suffolk County Legislature. The resolution proposed a Formulary Plan for Pharmaceutical Services within the Suffolk County Medicaid Program, and read as follows:
      WHEREAS, the present cost in Suffolk County for pharmaceutical prescriptions under the Medicaid program totals nearly six million dollars yearly, and
      WHEREAS, a projected 25 to 30 percent of these charges could be eliminated by the use of a formulary, and
      WHEREAS, this formulary would include only those generic substitutes with sufficient bio-equivalency to assure the highest quality prescriptions, and
      WHEREAS, the use of this formulary would reduce the number of drug entries in our data processing bank from 15,000 separate categories to less than 5,000, and
      WHEREAS, the use of this formulary would significantly lower costs for administrative services and data processing, and
      WHEREAS, numerous local hospitals have employed the use of formularies to both lower the cost of pharmaceuticals while simplifying procurement procedures, therefore, be it
      RESOLVED, that a special committee shall be established by the Presiding Officer which shall be 10include, but not be limited to representatives of the County Legislature, the Department of Social Services, the Board of Health, and the Suffolk County Medical Society, wh10se first charge will be to create aormulary, and be it further
      RESOLVED, that this special committee shall also be charged with the responsibility for drafting an amendment to the Local Medical Plan which will establish guidelines for the use of this formulary in Suffolk County. ¹¹

      Although a drug formulary might have been allowed by state health and social services statutes, and New York State has since passed legislation that allows generic drug substitution, this resolution could not have been acted upon in 1977 because the New York State Education Law at that time still stated that any pharmacist who "... substitutes or dispenses a different article for or in lieu of any article prescribed, ordered or demanded, or puts up a greater or lesser quantity of any ingredient specified... or otherwise deviates from the terms of the prescription" would be guilty of a misdemeanor. ¹²
      Since the proposed legislative resolution mandated generic substitution, Suffolk County would have required approval from the State Department of Social Services, the Sate Department of health, and the State Education Department before implementing such a plan. In addition, the statement that "this formulary would include only those generic substitutes with sufficient bio-equivalency to assure the highest quality prescriptions," may have also caused legal repercussions. The reason for concern stemmed from the fact that the Food and Drug Administration still had not established any bio-equivalence requirements. ¹³   If the federal government had not been able to develop bio-equivalency/bio-availability regulations for drug product selection by pharmacists, then it could not have been expected that a local committee would have been able to create a drug formulary within a propitious period.

Alternative Four: Purchase Generic Drugs
      This alternative suggests that drugs for the Medicaid program be purchased only from a specific list of generic drug manufacturers. In this manner, the County would be able to limit both drug categories and their costs by limiting availability to generic manufacturers with the lowest prices.
      Since a generic drug list could not be used, the possibility of using a list of generic drug manufacturers seemed the next most likely alternative. Although this alternative could circumvent the antisubstitution laws and would reduce both drug and administrative costs, it still would not have been economically successful since it would have resulted in law suits and an injunction against the County. Manufacturers having products disqualified would be certain to file a class action to prove this measure a restraint of trade and an unlawful deterrent to free enterprise. This alternative was therefore abandoned in order to avoid lengthy and costly legal battles with private industry.

Alternative Five: County Pharmacies
      Another alternative for providing drug services would be to open county pharmacies. The Suffolk County Department of Health Services operates six Health Centers, none of which include pharmacies. The purchasing, storage, handling and dispensing of the limited number of medications that are available at these centers is performed without pharmaceutical supervision and therefore results in an undue burden upon the medical and nursing staff. Most of the drugs prescribed by physicians at these clinics are filled at local pharmacies. If county operated pharmacies are opened at these clinics, the profit margin paid retail pharmacies could be saved on al Medicaid clients seen at these facilities. Furthermore, if the county purchases drugs through competitive bids, it would be possible to buy drugs for less than the wholesale prices paid by retail pharmacies. In addition, revenue income could be generated from patients with the financial ability to pay for services. One drawback however, would be that it would take three years for each pharmacy to recoup the initial inventory and operating expenses. ¹⁴

      Although county pharmacies would not be able to supply all the needed pharmaceutical services, anymore than the health center clinics can supply all the needed medical services, whatever portion of client needs are serviced would represent a relative savings. Unfortunately, Suffolk County has traditionally refrained from providing medical services directly for clients, and whenever possible, continues to use outside private providers. Additionally, since county operated pharmacies would have to be budgeted through the Suffolk County Department of Health, the medical Assistance Administration can only recommend that a cost-benefit evaluation be conducted.

Alternative Six: Private Contract
      William Kroger tried to show that the taxpayer's dollar can frequently be made to go farther by letting private firms handle projects for the government, and wrote that:
    Business people believe the government should contract out more than it does. In the process, they say, the federal payroll would be reduced, and the cost to the American taxpayer would be less. They say private firms can do federal jobs with fewer people and, through improved efficiency, at less expense generally. ¹⁵
      Lutrin and Settle address the problem of the high cost of government by saying that:     Government expenditure policies are more susceptible to inept management than they are to problems of corruption. The marked increase in public expenditures among the affluent nations during the past century can often be attributed to increased public demands coupled with poor administrative practices, including overstaffing, inept accounting, incompetent personnel, unimaginative leadership, and pork barrel appropriations. ¹⁶
      A thorough analysis of the advantages and disadvantages of contracting a private agency to administer either the social services or Medicaid programs for Suffolk County would be beyond the scope of this study and of little practical value for two reasons. First, Suffolk County already possessed the necessary computer equipment so that there was no need to purchase additional equipment, and second, the Public Assistance Administration had already committed the department to the use of computerized client master files. ¹⁷       Although the entire program was not contracted out, private contracts are used to handle specific functions for the drug program. A private wholesale firm supplies monthly price file updates on magnetic computer tape and private key punch firms are used to handle seasonal drug claim backlogs. ¹⁸

Alternative Seven: Control of Overutilization
Fraud and Abuse

      This alternative would entail reviewing the utilization of medical services aimed at the detection and prevention of fraud and abuse by both providers and recipients. The primary deterrent to instituting these controls is the need to gather, store, retrieve, and monitor the huge amounts of pertinent information concerning Medicaid expenditures.
      John Jennrich states that only consumer cost-sharing or co-payment of medical care has the potential for large, effective utilization and cost savings. These techniques can reduce costs if they are applied to ambulatory care services, such as drugs, in which the consumer exercises some discretion about costs and utilization. ¹⁹
      Although requiring clients to make full or part payment for medications might reduce utilization, the majority of the expenditures would only be transferred from the Medicaid drug program back to eligibility income determinations. Similarly, if some form of client subsidy program, such as the Food Stamp Program, was instituted, then administrative expenses would also remain virtually unchanged. Furthermore, having Medicaid clients pay for ambulatory services could effect counterproductive results because patients might opt for more expensive inpatient care since it would be unlikely that patient cost-sharing would ever be extended to inpatient care for Medicaid recipients.
      The San Joaquin Foundation for Medical Care Program and the Tennessee Medicaid Program had each developed methods for automated drug reviews. The San Joaquin system evaluates and produces reports on patients receiving: 1) twelve or more prescriptions; 2) over thirty dollars of medication within a thirty day period; 3) the same drug from two pharmacies on the same day; 4) services from four or more pharmacies within thirty days; 5) combinations with more than four prescriptions in ant one therapeutic category; or 6) medications capable of certain potential drug-drug interactions. During the first year, this monitoring program was successful in effecting over a twelve percent cost saving. ²⁰
      In Tennessee, a drug utilization program continuously monitors and records: 1) the top fifty recipients; 2) the top fifty prescribers; 3) the number of claims and dollars expended for each pharmacy; 4) patients utilizing more than two pharmacies or three physicians within a single month; 5) prescriptions being renewed too frequently; 6) prescriptions for abnormally low quantities, or quantities in excess of manufacturer's recommended dosage; and 7) potential drug-drug interactions. ²¹
      Since monitoring enormous amounts of information is a key requirement of programs for controlling overutilization, and/or fraud and abuse, it would be virtually impossible to institute any of these alternatives unless an automated program was implemented.

Alternative Eight: Automated Program
      The conversion of the Public Assistance program to an electronic data processing (EDP) system made it not only possible for, but even predisposed, the Medical Assistance Administration to implement a computerized system. Automation offered the potential for solving the problems associated with cost containment, the increasing claims volume, the availability of program information, and the development of a management information system. In addition, an automated program could also be expanded and coupled to one or more of the other alternatives, such as using county pharmacies, private contracts, and/or controlling overutilization, fraud and abuse.
      Martin and Perkins acclaim that:
    The computer has had an impressive impact upon both business and governmental organizations and how they operate and are managed. Although few clerks have been discharged because of the computer, we would have had great difficulty in coping with the explosive growth of paperwork in recent years if computers had not been developed, and clerical costs have been strikingly reduced in many companies. ...
    Despite the importance of the automation of clerical activities, an even more valuable benefit of computers is obtained through their use to provide the entire management structure with the information required at the time it is needed to manage the organization most effectively. ...
    Such a system is indeed a tool for controlling current operations, and one that also gathers historical information for management evaluation of performance as a by-product. ²²

Summary

      Based upon the preceding analysis, the first four alternatives to either transfer, limit, or discontinue services were deemed as not feasible at the time that the decision had to be finalized. Of the four remaining alternatives, replacing the manual system with an automated program promised to be most fruitful. It should, however, be noted that actual budgetary drug expenditures still might not have been reduced below the existing level. Increases in the eligible population, the scope or number of services, and/or the rate of inflation are variables which although predictable are not always controllable at the County level. In addition, as health care improves, the net costs could also increase due to the additional treatments that would not have occurred if patients had not lived longer or been cured as a result of the original treatment. Under these conditions, any system improvements would therefore be more effective in controlling and monitoring, rather than actually reducing expenditures. The next chapter will present the manner in which the existing automated system evolved and describe the impact that it had upon the drug program.

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CHAPTER III

DEVELOPMENTOF THE PMIS

The Model System
      Basically, there are two methods for the implementation of application ¹ software:
      1. design, develop, and debug a system to process the jobs and tasks which are unique to the organization, or
      2. purchase an existing turnkey, packaged, or canned system so that time does not have to be spent duplicating existing programs.
      Due to the imminent claims processing and cost containment problems, the Medical Assistance Administration chose the second option and purchased a copy of the Monroe County Model Medicaid Program. Although Medical Assistance did not originally make direct use of the Touche Ross and Company consulting firm, this consultant's suggestions to the Public Assistance Administration led to the conversion of the entire PA caseload onto an electronic data processing system. It thereby became possible for both PA and MA to update and maintain their entire caseload through a common turnaround document that enables the capture and storage of the key information for each case on a master file. Once these modifications were made, Medical Assistance was able to convert to an automated claims processing and statistical reporting system. The Model System was designed to verify both client and provider eligibility and then validate the charges for every claim submitted.
      By enrolling the services of a consultant firm, Suffolk was able to receive in the words of Robert Heller:
    ... for its fee, and for a time, the services and advice of men who (if its choice has been good) have broader experience, superior intelligence, more impressive backgrounds, and sharper all-round competence.... ²

      In addition, Berkley states that consultants can be used to serve the following three purposes:

    First of all, consultants can be a way of getting around civil service laws. An agency can hire the people it wants when it wants and for how long it wants without having to put up with civil service restrictions if it can classify and fund them as consultants....     The second advantage which the consultant possesses is his independence. ... if an organization is really determined to utilize what the consultant has to offer, it may find that the most valuable thing he has to offer is his detached perspective. ...
    One final advantage involved in consultant usage is worthy of note for it is of particular applicability in the public sector. Consultants, unlike most public employees, are easily disposed of. ³

      Sanders summarizes consultant assistance as follows:

    We have seen that during the earlier systems study stages consultants can often be used to advantage by alert managers to assist in such areas as systems design and hardware/software selection. Prior to systems conversion, they can offer sound advice on personnel and organizational matters associated with the forthcoming changes. And we have seen that packaged application programs, available from software consulting organizations, may be used during the implementation stage to shorten the disruptive conversion period. In addition, consultants are frequently retained during the conversion stage because (1) the firm's computer staff is too small to finish the mammoth transition job on time; (2) the firm's staff lacks the necessary training, knowledge, and experience to complete the job satisfactorily without some type of assistance; (3) consulting organizations can provide needed training in systems analysis and programming (and they can recommend and incorporate the use of data processing standards and controls into such training); and (4) it is judged to be more economical to :farm out" certain activities than to attempt to complete them internally. ⁴

      Ross, however, cautioned against the use of consultants who recommend turnkey systems by writing:

    Be careful! These guys are foxes who like to eat chickens! Their natural inclination is to promise everything without too much regard for that eventual day when they depart and leave you holding the key - or bag. In most cases, the consultant or manufacturer is concerned more with the machine than he is with management solutions.
    On the average, it is probably true that most companies are over computerized by about 20%. In many cases this computer "fat" is the result of strong marketing programs offered by manufacturers and to a lesser extent the "overcomputerization" recommended by consultants. This situation is particularly regrettable when more powerful machines are installed in anticipation of management systems that never seem to materialize.
    There are other good reasons for going slow in allowing consultants or manufacturers to make your computer and MIS decisions. First, there is a good chance that you will have to spend a great deal of time educating them in the operations of your company before they are in a position to make recommendations. Second, installing the system without substantial preparation is likely to result in some chaos. And third - and this is a general rule - if the buyer doesn't have the personnel who are capable of designing the organization's MIS, it is unlikely that they will have the expertise to operate those that were designed and installed by the outsider. ⁵

      It may be ironic, but the existing Suffolk County PMIS, owes its evolution to a combination of at least three basic types of miscommunication between the Monroe County, Suffolk County, and consultant personnel; allness, indiscrimination, and frozen evaluations. William V. Haney offers the following definitions and explanations:

    Allness, then, is the attitude of one who is unaware he is abstracting and thus assumes that what he says or "knows" is absolute, definitive, complete, certain, all-inclusive, positive, final - and all there is (or at least all there is that is important or relevant) to say or know about the subject. ... Allness will tend to occur:
1. When one talks, writes (or abstracts in any manner), is unaware that he is abstracting, and thus assumes he has covered it all. ...
2. When two or more people abstract different details from a given situation, are unaware that they are abstracting, and thus each assumes that what he "knows" is all. ...
3. When one evaluates a group on the unconscious assumption that his experience with one or a few members holds for all. ...
4. When one becomes closed to the new or different. ...
    We shall use the term, indiscrimination, to represent the behavior which occurs when one fails to recognize variations, nuances, differences; when one is unable or unwilling to distinguish, to differentiate, to separate apparently like things from one another. Indiscrimination may be defined, then, as the neglect of differences, while overemphasizing similarities. ...
    When one unconsciously (or perhaps deliberately) spreads an evaluation over the future and/or over the past, then, disregarding changes in whatever he is judging (a person, group, situation and so on), we say that he has frozen his evaluation. ...
    The frozen evaluation seems to occur most frequently when one somehow assumes nonchange. ⁶

      The Model Medicaid System had been operating effectively in Monroe County. Since the system had been running well an attitude of allness prevailed. Those involved believed that the system was complete and contained all the information and applications software that would be necessary. When the Suffolk County analysts were conducting their original evaluation, they did not fully appraise the situation. By concentrating on similarities between the needs of the two counties and neglecting the differences, their attitudes suffered from indiscrimination. Once Suffolk finally began running on the system, the fact that differences do actually exist quickly became apparent. After several months of delaying, the frozen evaluations pattern of miscommunication also surfaced. The applications programs required changing and the drug price file was not being updated. The stale information caused delays in payments and rejected claims quickly backlogged creating further delays and processing problems. It seemed as if Murphy's Law, "If anything can go wrong, it will," ⁷ and Murphy's Law of Thermodynamics, "Things get worse under pressure," ⁸ had been written specifically for this occasion.

THE NEW DESIGN
      The first corrective measure taken was to increase the size of the drug file. On April 1, 1975, Suffolk County began processing drug claims using a copy of the Model Medicaid price file that contained only 4,000 drug records. By December 1978, the file had been increased to include nearly 16,000 drug records. ⁹   In addition, manual and automated price file update procedures were developed into a file maintenance subsystem. As Heany explains, "File maintenance is the periodic updating of files to incorporate changes that have occurred during a given period." ¹⁰
      First, a program was developed to allow drug record additions, deletions, and/or changes through the on-line use of a Burroughs 830 input and video display monitor; more commonly referred to as a CRT (Cathode Ray Tube) or TD (Television Display). In this way, rejected claims can be reviewed and whenever necessary, the price file can be immediately updated so that all similar claims will be computer processed. Next, an automated monthly update subsystem was developed and implemented. Current drug prices are now maintained through update information gathered from magnetic tapes supplied by a drug wholesaler consultant firm and the New York State Department of Social Services. Input, processing, and output data controls were also incorporated into the subsystem to assure the accuracy and propriety of any new data entering the file. ¹¹   Finally, at the end of each run, the subsystem produces computer printout audit trails and management reports for the manual review of all the preceding file activities. ¹²
      During 1976 and 1977, cost containment amendments to the New York State Social Services and Education Laws revised the policies for coverage and reimbursement of both non-prescription and prescription medications under the Medicaid Program. ¹³   Previous to the passage of these amendments, any medication prescribed by a physician was Medicaid reimbursable. In accordance with these cost containment amendments, reimbursement became limited to only the drugs included on the New York State Medicaid Reimbursable Drugs list when ordered by a physician's prescription. Reimbursement for these drugs was also limited to maximum prices established by the New York State Department of Health for nonprescription drugs, and the New York State Department of Social Services for prescription drugs. Copies of the Medicaid Reimbursable Drugs list were sent to all physicians and pharmacists providing services to Suffolk County recipients, and monthly State price revisions available as microfiche for participating pharmacies.
      Because these mandated revisions were going to drastically change the manner in which drug claims were being handled, an entirely new drug program had to be developed. Both the Model Medicaid drug price file and the Automated Validation of Charged (AVC) program had to be restructured. The price file was redesigned so that each drug record was expanded to allow for the addition of two new fields; a Generic NDC Code and corresponding Effective Date. ¹⁴   In this manner, the AVC program could be directed through this chaining mechanism to search out the appropriate New York State mandated price maximums. These changes allowed a unique new flexibility to the Suffolk County pharmacy program by allowing compliance with the new State mandates and simplifying file maintenance. In other words, this framework established a computerized drug formulary system with the capability of linking any categories or combinations of drugs and establishing maximum prices. By the end of 1976, over 90 percent of the drug claims were being computer validated, reviewed, price adjusted, and paid without the need for manual review. ¹⁵

THE REPORTING SYSTEM
      Once the newly designed system was implemented and the claims processing and payment needs of the program were being met, it then became possible to begin evaluating if the information and cost containment needs were being satisfied. The claims history file that captures and stores the pertinent information on every claim paid is the basis for all utilization reports. From this master history file, all claims, client, provider, expenditure, utilization, and other management reports are extracted. Since claims are processed and paid on a weekly run basis, reports are also generated routinely on a weekly and monthly timetable. However, although monthly reports are made to coincide with calendar months, the weekly reporting system relates to workload production demands so that any number of weekly runs can be combined to form the corresponding monthly summary extracts. Claims summary reports are broken down according to provider and client utilization on a routine monthly basis, but specific extract requests can also be run upon request using the QUR/DP EXTRACT REQUEST form shown in the Appendix. ¹⁶
      The pharmacy unit was able to take the highly technical language of pharmacy, marry it to the highly technical language of the computerized system, and translate it all back into familiar management terms. Jerome Kanter lists the ability to obtain reports and information previously unavailable as the most significant benefit of data processing and states that:     ... The payoff of computerization is not in reduced costs but in providing benefits in the form of more timely information. ¹⁷

      The final step in evaluating the PMIS will now be to review some of the information contained in these reports and determine what affect the new program has had upon drug expenditures. Although the Medical Assistance Program converted to the Model System on April 1, 1975, the development of the pharmacy subsystem and the institution of the state mandated cost containment drug formulary were not completed until the last quarter of 1976. In 1974, 1975, and 1976, drug expenditures increased by 11 percent, 20 percent, and 31 percent respectively. In 1977, drug expenditures were reduced 23 percent, and still have not climbed back to the 5.4 million dollar level of 1976. The 1978 and 1979 drug expenditure levels were also at least one million dollars below the 1976 level. ¹⁸   Further analysis of the drug claims statistics indicates that in 1977, 1978, and 1979, 52 percent, 57 percent, and 58 percent respectively of all paid pharmacy claims were computer reduced from the original amounts billed. In 1978 and 1979 alone, the AVC program was responsible for saving over a half million dollars through price adjustments. ¹⁹   The Suffolk County Medicaid pharmacy program can therefore boast to having stabilized drug expenditures for the last three consecutive years and effectively implemented cost containment measures through the development of the PMIS.
      If Suffolk County Medical Assistance had simply dumped the original manual records onto the computer files, without updating the system, it would have been guilty of perpetuating what Joel E. Ross referred to as a system which would merely "increase inefficiency at an accelerating rate." ²⁰   However, through the rearrangement, improvement, classification, and updating of information, the system is able to fulfill the key MIS roles of improving decision making and the management process.
      The next and final chapter of this study will be devoted to an overall review of the development of the Suffolk County Pharmacy Management Information Subsystem, but this time with a shift in emphasis from the how it evolved, to the why it evolved as it did.

[Back to Top]      [Chapter IV]      [ENDNOTES]      [End of Thesis]

Begin Page 40

CHAPTER IV

A SECOND ANALYSIS

      A decision analysis was presented in Chapter II, which followed the traditional rational comprehensive approach. This chapter will be a second review of the events leading to the development of the PMIS in Suffolk County. It will begin with an explanation of traditional rational acting, and then present alternative explanations for government behavior.
Government Behavior

Rational Acting
      As Lee and Johnson explained:
    Decision making according to the pure rationality approach consists of a series of ordered, logical steps. First, a complete specification of an organization's or society's goals must be ranked by priority. Second all possible alternatives are identified. The costs of each alternative are compared with anticipated benefits. Judgments are made as to which alternative comes closest to satisfying one's values. The alternative with the highest payoff and/or least cost is chosen. Pure rationality theories assume that complete and perfect information about all alternatives is both available and manageable. Decision making, therefore, is choosing among alternatives to maximize some objective functions. ¹

      E. S. Quade wrote that:
    ... technology and events move so rapidly that natural trial and error, give-and-take processes can become too catastrophe-prone for comfort before the process approaches completion...
    Policy analysis is valuable because it can help a decision-maker by providing information through research and analysis, by isolating and clarifying efforts, by generating new alternatives, and by suggesting ways to translate ideas into feasible and realizable policies. Its major contribution may be to yield insights, particularly with regard to dominance and sensitivity of the parameters. ...
    Analysis can help with almost every public policy decision, from the most routine to the most profound, e.g., from a choice among ways to improve record-keeping in an employment office to critical choices the outcome of which may determine whether we live or die. ...
    ... For people who believe that rational analysis and systematic planning can be done, and done adequately if not perfectly, policy analysis is seen as an important tool. ...
    The purpose of policy analysis is to help (or sometimes influence) a decision-maker to make a better decision in a particular problem situation than he might otherwise have made without the analysis. ²

      Graham T. Allison presents three frames of reference for analyzing the Cuban missile crisis. The first frame of reference is in terms of a rational actor model. This model expects departmental activities to mimic the actions of a unitary, rational decision-maker; centrally controlled, completely informed, and value maximizing. The trademark of a rational actor analyst is the attempt to explain events by recounting the aims and calculations of the government. By examining the problems and character of the chosen action, the classical analyst eliminates some aims as implausible, and calculates how, in a particular situation, with certain objectives, the action can be explained as the rational value-maximizing choice. This model depicts nations, governments, and other groups as having the human capability for rational action and equates their decision-making capabilities. ³
      Chapter II of this study presented eight possible alternatives for handling the pharmacy program; the final result being the development of an automated PMIS. The information presented tried to show that an automated program would be the most rational approach, but actually, the PMIS was never planned or developed from any specific, ordered, central, unitary, rational, comprehensive, or value maximizing decision.

Organizational Process Paradigm
      In this Model II Organizational Process Paradigm, Graham T. Allison summarizes government behavior relevant to any important problem as reflecting the independent output of several organizations, partially coordinated by government leaders who can substantially disturb, but not substantially control, the behavior of these organizations. At any given time, a government consists of existing organizations, each with a fixed set of standard operating procedures to coordinate its organizational programs. The behavior of these organizations, and consequently the behavior of government, relevant to an issue in any particular instance is, therefore, determined primarily by routines established in these organizations prior to that instance. The Organizational Process Model uses the Dominant Inferences Pattern for explaining government behavior as incremental and differing only marginally from what existed the previous instant. The best explanation for an organization's behavior at any specific time (t) would be (t-1), and the best prediction of what will happen at (t+1), would be (t). ⁴

Incrementalism and Muddling Through
      Charles E. Lindblom disputes any decision-maker's ability to achieve a completely rational comprehensive decision, and states that:
    All analysis is incomplete, and all incomplete analysis may fail to grasp what turns out to be critical to good policy. ... The choice ... is simply between ill-considered, often accidental incompleteness on one hand, and deliberate, designed incompleteness on the other. ⁵

      Instead, Lindblom prefers the method of successive limited comparisons in which the decision-maker only chooses between marginal or incremental differences. According to Lindblom, public agencies are in effect, usually instructed through their prescribed functions, as well as their political and legal constraints, to restrict their attention to relatively few values and alternative policies. He then mentions that:
    ... In addition, it can be argued that, given the limits on knowledge within which policy-makers are confined, simplifying by limiting the focus to small variations from present policy makes the most of available knowledge. Because policies being considered are like present and past policies, the administrator can obtain information and claim some insight. Non-incremental policy proposals are therefore typically not only politically irrelevant but also unpredictable in their consequences.     ... Policy is not made once and for all; it is made and remade endlessly. Policy-making is a process of successive approximation to some desired objectives in which what is desired itself continues to change under reconsideration. ⁶

Partisan Mutual Adjustment and Pluralism       With partisan mutual adjustment, Lindblom also looks beyond government behavior as the result of a single decision making actor or even a centrally coordinated agency. He therefore wrote:
    ... Without claiming that every interest has a sufficiently powerful watchdog, it can be argued that our system often can assure a more comprehensive regard for the values of the whole society than any attempt at intellectual comprehensiveness. ...
    Mutual adjustment is more pervasive than the explicit forms it takes in negotiation between groups; it persists through the mutual impacts of groups upon each other even where they are not in communication. For all the imperfections and latent dangers in this ubiquitous process of mutual adjustment, it will often accomplish an adaptation of policies to a wider range of interests than could be done by one group centrally. ⁷

      According to Lindblom, partisan mutual adjustment:
    ... takes the form of fragmented or greatly decentralized political decision making in which the various somewhat autonomous participants mutually affect one another ...
    ... In many circumstances their mutual adjustments will achieve a coordination superior to an attempt at central coordination, which is often so complex as to be beyond any coordinator's competence. ...
    ... The coordination of participants ... arises from their reciprocating effects on each other, not through a centrally analyzed coordination.
    ... In partisan mutual adjustment and all politics, participants make heavy use of persuasion to influence each other; hence they are constantly engaged in analysis designed to find grounds on which their political adversaries or indifferent participants might be converted to allies or acquiescents.
    ... fragmentation of policy making and consequent political interaction among many participants ... are methods ... of raising the level of information and rationality brought to bear on decisions. ⁸

      Francis E. Rourke also emphasizes the pluralistic nature of government bureaucracies and stresses the fact that agencies must master the art of politics as well as the science of administration. He believes that bureaucrats must learn to work through the channels of interest group politics. A single agency may draw power from several sources, and there is no way of telling how much of any agency's success should be attributed to bureaucratic expertise, constituency strength, organizational vitality, or skillful leadership. According to Rourke, agencies derive their power from essentially two sources: (1) their ability to create and nurse constituencies, and (2) the technical skills that they command and can focus on complicated issues of public policy. Each agency must constantly create a climate of acceptance for its activities and negotiate alliances with powerful legislative and community groups. ⁹

Governmental Politics Paradigm

      The Governmental (Bureaucratic) Politics Model categorizes government behavior as political resultants. Allison describes the behavior as political because there is competitive bargaining along regularized circuits and players. Yet, it is also a resultant, because a mixture of conflicting preferences and unequal powers of various individuals produce a result that is distant from what any person or group intended. It is not a chosen solution to a problem, but rather a result from the compromise, conflict, and confusion of officials with diverse interests and unequal influence.
      According to Allison, "The aphorism 'Where you stand depends on where you sit' has vertical as well as horizontal application." ¹⁰   In addition, where you sit also influences what you will see, and as you change your seat, or hat, you will often change where you stand. Many different individuals within each government agency speak and act according to their own perspectives and priorities. The inherent inconsistencies of government workings include misunderstandings, miscommunications, and misjudgments. Even agreement on what must be done does not guarantee the action, because each player might still believe that the job belongs to someone else. Allison, therefore points out that the evolution of inconsistencies becomes understandable, or even predictable, and frequently will add to the fact that the final resultant is unrelated to any of the original plans. ¹¹

PMIS Behavioral Analysis
      Since the PMIS was not developed from a comprehensive plan, the sequences of changes and conflicts that led to the existing program as a resultant will be reviewed. Although the pharmacy unit managed to develop the PMIS, its efforts were generally focused as a continuing pursuit to solve specific problems, make mandated changes, and improve operations. This statement, however, is not meant to suggest that there is no need for planning. Programs should be planned and organized to get everybody pulling in the same direction, as much as possible, in order to improve efficiency and increase uniformity of available services. Ross states that, "The reasons for MIS planning are the same as for planning in general: it offsets uncertainty, improves economy of operations, focuses on the objectives, and provides a device for subsequent control of operations." ¹²   Donald H. Sanders adds that, "The planning function looks to the future; to plan is to decide in advance a future course of action." ¹³   The challenge, however, facing the pharmacy unit was, and continues to be, the coordination of legal mandates with public and private interest group pressures and the constant revision of earlier plans due to changing conditions.

      As mentioned in the Introduction, the first pressures to initiate movement toward the development of the PMIS, were the accelerating increases in drug expenditures and claims volume. Next, there was the commitment made toward automation by the Public Assistance and Medical Assistance Administrations, and the implementation of the Model Medicaid System. The initial claims payment backlogs from the manual system were only increased by the enormous rejection rate and failure of the Model System. The pressures caused by the demand for more drug services during the winter cold and flu season further aggravated this backlog. The pharmacy provider uproar resulting from payment delays grew into a withdrawal of services. This pharmacy boycott, therefore unleashed political pressures that forced the county bureaucracy to react at crisis speeds to process and pay the backlogged claims.
      Once the size of the drug file was increased and the program began processing claims on a timelier basis, the introduction of cost containment legislation by the state DSS and DOH caused additional problems and confusion. The inherent competition and friction between these departments has, in spite of their formalized Cooperative Agreement, demonstrated that cooperation and coordination between these departments is not an automatic process. Their shared responsibilities and combined efforts have led to two different formats in the list of Medicaid Reimbursable Drugs, with at least five different formats for drug pricing, a separate list of Therapeutically Equivalent Prescription Drugs, and a continuous stream of revisions to which physicians and pharmacists must refer. Physicians are therefore protesting that Medicaid is trying to dictate how they must practice medicine, and pharmacists are complaining that they are being enmeshed in bureaucratic red tape. Although most of the pharmacy providers are now participating in the Medicaid program, they have become much more cautious and selective in choosing the services they are willing to provide.
      Probably the greatest irony of the drug cost containment program is that legal and administrative pressures are being aimed at the retail pharmacy industry because it is the most visible and politically disorganized area rather than the area for greatest potential savings. In the pharmaceutical industry, drug manufacturers and wholesalers have used fair trade, patent, and anti-substitution laws to effect imperfect competition and maintain prices above normal competitive pressures. Retail drug prices, however, have traditionally been one of the most, if not the most, competitive parts of our health care system. Competitive pressures from generic substitution laws, mandatory price posting, and the lifting of restrictions on professional advertising are all evident at the retail supply level between large chains, small chains, and independently owned pharmacies.
      Medicaid recipients are also being confused and even alienated by these program inconsistencies. Recipients cannot understand why they sometimes are denied services by pharmacies, even after they have been determined to be eligible. Furthermore, if the provider's claim for payment is processed before the case has been opened on the computer files, or if due to human or mechanical error, Murphy's Law prevails and the case is not coded properly, the claim will be rejected from payment. Both the recipient and the provider will then be faced by the Herculean task of trying to prove to the bureaucracy that something has gone wrong, and then by the even more difficult task of trying to correct the error so that it will not reoccur.
      The fact that the program is not the utopian answer for any of the constituency or interest groups, however, should not detract from the value of the PMIS. Although the existing PMIS does not conform to the ideal plan of any of these groups, it is a comprehensive compromise resultant that effectively administers the local pharmacy program.

Conclusion

      As stated in the Introduction, the primary question facing the Medical Assistance Pharmacy Unit was whether it would be possible to implement and maintain an effective automated pharmacy program at the local county government level. The existence of the current PMIS allows this question to be answered in the affirmative. The PMIS fulfills both the objectives of a MIS system and the objectives of the local Medicaid Pharmacy Program. The system has been able to incorporate cost containment procedures, handle claims processing, and provide needed management oriented program information. In addition, the flexibility, comprehensive, and sophisticated nature of the system, allows it to respond to the continually changing needs and political pressures of its environment.

Begin Page 52

APPENDIX
SOURCE OF FUNDS

Department of Social Services expenditures are mandated by Federal and State law and the Federal, State and County governments share the costs of providing these services. The cost sharing varies from program to program, however in most cases the Federal government funds 50%, the State government 25%, and the County 25%. The following chart indicates sources of funding for the last four years.

             Percent Distribution of Source of Funds

      Source of funds:     1976    1977    1978    1979
      Federal                     49.3     46.0     48.3     46.8
      New York State       26.7     27.0     27.5     25.9
      Suffolk County       21.8     24.1     20.6     23.6
*Department Income     2.2       2.9       3.6       3.7
            TOTAL:          100.0   100.0   100.0   100.0

In 1979 the Department was the conduit for 94.4% of the Federal revenues and 69.2% of the State revenues coming into the County General Fund.

*Primary source of departmental income is payments for funds previously expended.

     SOURCE: “Suffolk County Department of Social Services 1979 Annual Report”, Suffolk County Government Print Shop, 1980, p. 4a.

End of Page 52

EXPENDITURES BY SOURCE OF FUNDS

__________________________________________________________________________
Year Total Federal State County Federal State County
Claimed Share Share Share % % %
__________________________________________________________________________
1971 40,477,277 19,388,615 10,564,570 10,524,092 47.9 26.1 26.0
1972 42,440,734 20,583,756 10,909,269 10,949,709 48.5 25.7 25.8
1973 48,480,548 23,706,988 12,411,020 12,362,540 48.9 25.6 25.5
1974 57,729,733 28,864,887 15,009,740 13,855,146 50.0 26.0 24.0
1975 69,114,082 33,299,271 17,382,440 18,432,372 48.2 25.2 26.6
__________________________________________________________________________

     SOURCE: “Suffolk County Department of Social Services 1975 Annual Report,” Suffolk County Government Print Shop, 1976, p.26.

EXPENDITURES BY SOURCE OF FUNDS

_________________________________________________________________________
Year Total Federal State County Federal State County
Claimed Share Share Share % % %
_________________________________________________________________________
1975 69,114,082 33,299,271 17,382,440 18,432,372 48.2 25.2 26.6
% chg. + 28% + 28% + 31% + 24%
75-76
1976 88,293,312 42,695,247 22,799,033 22,799,032 48.4 25.8 25.8
% chg. (- 8%) (- 11%) (- 5%) (- 5%)
76-77
1977 81,167,569 37,903,878 21,582,561 21,681,130 46.7 26.6 26.7
% chg. + 11% + 14% + 8% + 9%
77-78
1978 90,208,707 43,094,397 23,411,610 23,702,700 47.8 26.0 26.3
_________________________________________________________________________

The amount claimed for federal and state reimbursement is
Greater than amount shown on expenditure chart because MA claims reimbursement for
the County Infirmary while the infirmary�s expenditures are recorded elsewhere in the
County budget.

     SOURCE: “Suffolk County Department of Social Services 1978 Annual Report,” Suffolk County Government Print Shop, 1979, p. 20.

EXPENDITURES BY SOURCE OF FUNDS

________________________________________________________________________
Year Total Federal State County Federal State County
Claimed Share Share Share % % %
________________________________________________________________________
1977 81,167,569 37,903,878 21,582,561 21,681,130 46.7 26.6 26.7
% chg. + 11% + 14% + 8% + 9%
77-78
1978 90,208,707 43,094,397 23,411,610 23,702,700 47.8 26.0 26.3
% chg. + 12% + 13% + 11% + 10%
78-79
1979 101,031,111 48,805,574 26,084,735 26,140,802 48.31 -25.82 -25.87
_________________________________________________________________________

     SOURCE: “Suffolk County Department of Social Services 1979 Annual Report,” Suffolk County Government Print Shop, 1980, p. 23.

[Back to Top]      [INTRODUCTION]      [ENDNOTES]      [End of Thesis]

Begin Page 57
PROGRAM NO. MEDX51 SUFFOLK COUNTY DEPT OF SOCIAL SERVICES - MEDICAID PAGE 443 REPORT NO. PME511 PRICE FILE LISTING (OPTION P1) DATE 12/23/80 NATL DRUG LEG PKG. UNT EFF PKG. O LABELER GEN GENERIC P THP DOS CODE STA SIZE NAM DATE PRICE I SHORT NAM STRENGTH EFF DATE NDC CODE A CLS FRM DESCRIPTION --- PRODUCT NAME 090174 3.00 O 00022-0210-10 R 100 TAB 010179 2.35 R MCKESSON 10 MG 0 009 TAB ISOSORBIDE DINITRATE 010180 1.90 E 00022-0215-10 O 100 TAB 010177 1.60 R MCKESSON 25 MG 070176 0GEN0-5555-55 0 031 TAB MECLIZINE HYDROCHLORIDE 00022-0229-19 R 250 CAP 010179 6.95 A MCKESSON 150 MG T.D. 091577 0GEN0-9999-99 0 009 SRC PAPAVERINE HYDROCHLORIDE T.D. 00022-0236-01 R 1000 TAB 010180 29.10 A MCKESSON 25 MG 010180 00022-0236-16 0 015 TAB AMITRIPTYLINE HCL 00022-0236-10 R 100 TAB 010180 2.91 A MCKESSON 25 MG 010180 00022-0236-16 0 015 TAB AMITRIPTYLINE HCL 00022-0236-16 R 1000 TAB 010180 29.10 A MCKESSON 25 MG 0 015 TAB AMITRIPTYLINE HCL 00022-0238-10 R 100 TAB 060180 7.00 R MCKESSON 50 MG 0 015 TAB AMITRIPTYLINE HCL 00022-0283-50 R 80 CC 100173 0.83 O MCKESSON 200,000/5CC 0 071 PWR KESSO-PEN FOR SYRUP 00022-0283-55 R 150 CC 100173 1.07 O MCKESSON 200,000/5CC 0 071 PWR KESSO-PEN FOR SYRUP 00022-0306-10 R 100 TAB 010179 1.65 A MCKESSON 5 MG 0 004 TAB TRIHEXYPHENIDYL HCL 010180 1.50 E 00022-0314-10 O 100 TAB 010173 0.79 O MCKESSON 50 MG B-6 070176 0GEN0-2111-82 0 021 TAB PYRIDOXINE HCL 010176 1.99 R

[Back to Top]      [INTRODUCTION]      [Conclusion]      [End of Thesis]

Begin Page 59

PHARMACY EXPENDITURES M-4 DRUG CLAIMS 1973 1974 1975 1976 1977 1978 1979 Expenditure $3.1 $3.5 $4.1 $5.4 $4.2 $4.4 $4.2 (Millions) % Change - +11% +20% +31% -23% +5% -5% $ Change - +$0.3 +$0.7 +$1.3 -$1.2 +0.2 -0.2 (Millions)

     SOURCE: “Annual Pharmacy Report for 1979,” Suffolk County Government Print Shop, 1980, p.7.

Begin Page 60

M-4 DRUG CLAIM STATISTICS (FROM PME 401 REPORTS) Total Processed Total Total Total Dollars Processed Claims Paid Actual Services Not Paid Claims Dollars Claims Dollars _______ _____________ _______ ________ ________ __________ 1977 630,152 $5,113,761.98 537,354 $4,190,246.00 941,260 $923,515.93 1978 608,501 5,267,804.17 532,479 4,419,019.00 856,892 848,785.13 1979 501,100 5,095,833.49 433,098 4,188,156.50 721,913 907,676.99 M-4 DRUG ERROR ANALYSIS (FROM PME B91 REPORTS) M-4 Claims Claims % Claims Returned Disallowed Claims Adjusted Average NDC E81 Adjusted Divided by Dollars Prescription Errors $ = 0 E12 Paid Unpaid Price Paid _______ ___________ _______ ________ ________ ____________ 1977 14,500 1,852 278,432 52% $119,553.65 $4.45 1978 8,978 1,499 302,038 57% 381,587.02 5.16 1979 6,965 2,117 251,624 58% 146,206.43 5.80

     SOURCE:  “Annual Pharmacy Report for 1979,” Suffolk County Government Print Shop, 1980, p.8.

Begin Page 61

DRUG PRICE FILE MAINTENANCE REPORT

12/11/78 10/19/79 Drug Records Total 15,884 17,477 Records With Generic Chains 4,485 5,659 Drugs Not on OTC List 1,036 1,026 Drugs Not on Rx List 201 652 EAC, MAC Price Chains 3,248 3,981 Drugs Without Chains 11,399 11,818

     SOURCE:  “Annual Pharmacy Report for 1979,” Suffolk County Government Print Shop, 1980, p.9.

Begin Page 62
QUR/DP EXTRACT REQUEST FROM: _________________________________ DATE: __________________ FOR: __________________________________ TYPE REQUEST: [ ] Vendor By Date of Service (Vendor#) _______________ [ ] Client By Date of Service (Client#) _______________ [ ] Other - Describe & Specify Sequence and any totals desired ________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ====================================================================== ====================================================================== ====================================================================== Fields Available *Form Number (01) Accident Code (49) *Provider Number (02) Drug SRS (50) *Provider Type (03) Emergency Code (51) *Client Number (06) Therapeutic Class (52) *Batch Number (08) Initial Visit Code (53) *Claim Number (09) Care Type (54) *Date of Service From (10) Return (55) Date of Service To (14) Carrier (56) *Amount Due Adj=PAID (18) Distance/Miles (57) Date of Birth (19) Trip Type (58) Year of Birth (20) Clinic A/B (59) *Date Paid (23) SR-C-A (60) Zip Code (27) SR-C-B (61) *Adjustment Code (29) Refill Code (62) Category (30) Diagnosis (63) Case Type (31) Referring Provider (64) Sex (32) Referring Prov Type (65) Insurance Code (33) Referring Prov No. (66) Ethnic Code (34) NDC (67) Town Code (35) Fee/Rate/Price (68) Village Code (36) Place of Service (69) FP/FNP Code (37) TOS (70) Date of Admission (38) *DOS (71) Date of Discharge (42) *DOS-Year (72) Number of Days (46) *DOS-Month (73) Admit From (47) Quantity (75) Discharge To (48) *=Printable Field

ENDNOTES

INTRODUCTION

¹“Suffolk County Department of Social Services 1975 Annual Report,” Suffolk County Government Print Shop, 1976, pp.1-15.
²“County of Suffolk New York Adopted Budget 1976,” Suffolk County Government Print Shop, 1976, pp.XXIII-594.
³“County of Suffolk New York Tentative Budget 1978 Volume I Summary,” Suffolk County Government Print Shop, 1978, p.8.
⁴Refer to pages 52-55 of the Appendix for charts indicating funding sources for the Department of Social Services 1976 to 1979, and Medical Assistance expenditures for 1977 to 1979.
⁵The multiplier theory states that national income will rise as a result of an incremental increase of net investment or as a result of an injection of new money by the government into the income stream and the total sum will exceed the original disbursement. For further information the reader is referred to John Maynard Keynes, The General Theory of Employment, Interest and Money (New York: Harbinger, 1964) and Hugo Hegeland, The Multiplier Theory (New York: A. M. Kelley, 1966).
⁶“Suffolk County Department of Social Services 1974 Report,” Suffolk County Government Print Shop, 1975, pp.14-15.

CHAPTER I

¹“1975 Annual Report,” p.2.
²“1978 Annual Report,” p.17.
³“1975 Annual Report,” p.2.
⁴“1978 Annual Report,” p.17.
⁵Refer to page 56 of the Appendix for the Department of Social Services organizational chart.
⁶Leon K. Albrecht, Organization and Management of Information Processing Systems (New York: The Macmillan Company, 1973), p.3.
⁷Joel E. Ross, Modern Management and Information Systems (Virginia: Reston Publishing Company, Inc., 1976), pp.9-51.
⁸Edley W. Martin, Jr., and William C. Perkins, Computers and Information Systems: An Introduction (Illinois: Irwin and Dorsey Press, 1973), pp.41-45.
⁹Donald H. Sanders, Computers and Management in a Changing Society, 2d ed. (New York: McGraw-Hill Book Company, 1974), pp.4-63.
¹⁰Jerome Kanter, Management-Oriented Management Information Systems (New Jersey: Prentice-Hall, Inc., 1972), p.1.
¹¹Donald F. Heany, Development of Information Systems: What Management Needs to Know (New York: The Ronald Press Company, 1968), pp.7-8.
¹²Martins and Perkins, pp.13-23.
¹³Heany, p.92.
¹⁴Ross, pp.5-8.

CHAPTER II

¹“1975 Annual Report,” p.2.
²Robert D. Lee, Jr., and Ronald W. Johnson, Public Budgeting Systems, 2d ed. (Baltimore: University Park Press, 1977), pp.309-10.
³Ibid., p.287.
⁴Ibid., p.283.
⁵Robert Heller, The Great Executive Dream (New York: Dell Publishing Co., Inc., 1972), p.167.
⁶“Annual Pharmacy Report for 1979,” Suffolk County Government Print Shop, 1980, p.7.
⁷“Annual Pharmacy Report for 1976,” Suffolk County Government Print Shop, 1977, p.1.
⁸Thomas P. Lauth, “Zero-Base Budgeting in Georgia State Government: Myth and Reality,” Public Administration Review (September/October 1978), p.426.
⁹“Rx Prices and Sizes Increase,” New York State Pharmacist (June 1977), p.9.
¹⁰“Suffolk County Department of Social Services 1974 Annual Report,” Suffolk County Government Print Shop, 1974, p.15.
¹¹Suffolk County, Legislature, Committee on Legislative Finance. A Resolution for a Formulary Plan for Pharmaceutical Services within the Suffolk County Medicaid Program, Suffolk County Government Print Shop, 1977.
¹²New York State Education Law (1977), Title VIII, Article 137 Section 6816.
¹³“Efforts Underway to Scuttle DPS Legislation,” Apharmacy Weekly, vol. 16, no. 11 (March 12, 1977), p.1.
¹⁴“The Lilly Digest: A Preview of Community Pharmacy-1975,” New York State Pharmacist (June 1976), pp.24-26.
¹⁵William Kroger, “Contracting Out, One Way To Shrink Government Employment,” Nation�s Business (December 1977), pp.39-42.
¹⁶Carl E. Lutrin, and Allen K. Settle, American Public Administration: Concepts and Cases (California: Mayfield Publishing Company, 1976), p.131.
¹⁷Lee and Johnson, pp.1-20.
¹⁸“1975 Annual Report,” p.16.
¹⁹John Jennrich, “Putting Health Care Costs Under A Microscope,” Nation�s Business (November 1978), pp.77-85.
²⁰Marvin C. Meyer, Herbert Bates, Jr., and Robert G. Swift, “The Role of State Formularies,” Journal of the American Pharmaceutical Association, vol. n.s. 14, no. 12 (December 1974), p.665.
²¹Ibid., p.666.
²²Martin and Perkins, pp.12-14.

CHAPTER III

¹Kanter, p.143. Application software is the order processing or inventory control system end product; the system software is tied directly to the computer to assist the programmer in translating applications into machine language, and the operations group in scheduling and running the computer efficiently.
²Heller, p.295.
³George E. Berkley, The Craft of Public Administration, (Boston: Allyn and Bacon, Inc., 1975), pp.363-65.
⁴Sanders, pp.260-61.
⁵Ross, p.20.
⁶William V. Haney, Communication and Organizational Behavior Text and Cases, 3d ed. (Illinois: Richard D. Irwin, Inc., 1973), pp.299-392.
⁷Arthur Block, Murphy�s Law and other reasons why things go wrong! (California: Price/Stern/Sloan Publishers, Inc., 1977), p.11.
⁸Ibid., p.19.
⁹Refer to page 61 of the Appendix for chart showing drug price file maintenance report.
¹⁰Heany, p.102.
¹¹Sanders, pp.434-37.
¹²Refer to page 58 of the Appendix for chart indicating the system design.
¹³New York State, Chapter 77 of the Laws of 1977, 10 NYCRR 85.25.
¹⁴Refer to page 57 of the Appendix for a copy of a page from the price file listing.
¹⁵Refer to page 60 of the Appendix for chart indicating drug claim statistics.
¹⁶Refer to page 62 of the Appendix for a copy of the QUR/DP EXTRACT REQUEST form.
¹⁷Kanter, p.81.
¹⁸Refer to page 59 of the Appendix for chart indicating Pharmacy expenditures.
¹⁹Refer to page 60 of the Appendix for chart indicating drug claim statistics.
²⁰Ross, p.27.

CHAPTER IV

¹Lee and Johnson, p.16.
²E. S. Quade, Analysis for Public Decisions (New York: American Elsevier Publishing Co., Inc., 1975) pp.3-13.
³Graham T. Allison, Essence of Decision, Explaining the Cuban Missile Crisis (Boston: Little, Brown and Co., 1971), pp.10-38.
⁴Ibid., pp.67-100.
⁵Charles E. Lindblom, “Still Muddling, Not Yet Through,” Public Administration Review (November/December 1979), p.519.
⁶Charles E. Lindblom, "The Science of ‘Muddling Through,’" Public Administration Review 19 (1959) : 209-10.
⁷Ibid.
⁸Lindblom, "Still Muddling, Not Yet Through," pp.522-24.
⁹Francis E. Rourke, Bureaucracy, Politics, and Public Policy, 2d ed. (Boston: Little, Brown and Co., 1969), pp.81-90.
¹⁰Allison, p.176.
¹¹Ibid., pp.144-178.
¹²Ross, p.21.
¹³Sanders, p.170.

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BIBLIOGRAPHY

BOOKS

Albrecht, Leon K. Organization and Management of Information Processing Systems. New York: The Macmillan Company, 1973.

Allison, Graham T. Essence of Decision, Explaining the Cuban Miss1le Crisis. Boston: Little, Brown and Co., 1971.

Berkley, George E. The Craft of Public Administration. Boston: Allyn and Bacon, Inc., 1975.

Block, Arthur. Murphy�s Law and other reasons why things go wrong! California: Price/Stern/Sloan Publishers, Inc., 1977.

Haney, William V. Communication and Organizational Behavior Text and Cases. 3d ed. Illinois: Richard D. Irwin, Inc., 1973.

Heany, Donald F. Development of Information Systems: What Management Needs to Know. New York: The Ronald Press Company, 1968), pp.7-8.

Heller, Robert. The Great Executive Dream. New York: Dell Publishing Co., Inc., 1972.

Kanter, Jerome. Management-Oriented Management Information Systems. New Jersey: Prentice-Hall, Inc., 1972.

Lee, Robert D., Jr., and Johnson, Ronald W. Public Budgeting Systems, 2d ed. Baltimore: University Park Press, 1977.

Lutrin, Carl E. and Settle, Allen K. American Public Administration: Concepts and Cases. California: Mayfield Publishing Company, 1976.

Martin, Edley W., Jr., and Perkins, William C. Computers and Information Systems: An Introduction. Illinois: Irwin and Dorsey Press, 1973.

Pilgrim Health Applications. Medical Claims Processing and Quality Assurance Programs. Massachusetts: Arthur D. Little, Inc., 1977.

       . Title XIX Compliance: A Workable, Cost-Effective Pharmacy Audit Program. Massachusetts: Arthur D. Little, Inc., 1977.

Quade, E. S. Analysis for Public Decisions. New York: American Elsevier Publishing Co., Inc., 1975.

Ross, Joel E. Modern Management and Information Systems. Virginia: Reston Publishing Company, Inc., 1976.

Rourke, Francis E. Bureaucracy, Politics, and Public Policy, 2d ed. Boston: Little, Brown and Co., 1969.

Sanders, Donald H. Computers and Management in a Changing Society, 2d ed. New York: McGraw-Hill Book Company, 1974.

Sutherland, John W., ed. Management Handbook for Public Administrators. New York: Van Nostrand Reinhold Company, 1978.

Journals

�Annual Prescription Survey.� American Druggist (June 1976): 42-44.
Brody, Robert. �Why Medicaid Programs Work Well in Five States.� American Druggist (April 1980): 19-26.
Cohn, Jeffrey P. �Competitive Health Insurance-Cure for Rising Health Costs?� American Pharmacy, vol. n.s. 20, no. 6 (June 1980): 6-7.
�Computers for Pharmacy.� American Pharmacy, vol. n.s. 20, no. 3 (March 1980): 18-39.
�Efforts Underway to Scuttle DPS Legislation.� Apharmacy Weekly, vol. 16, no. 11 (March 12, 1977): 1.
�Health Care Problems Face Congressional Overdose.� Nation�s Business (September 1979): 49-50.
�Is Real Welfare Reform an Impossible Dream?� Nation�s Business (January 1979): 34-39.
Jennrich, John. �Putting Health Care Costs Under A Microscope.� Nation�s Business (November 1978): 77-85.
Kroger, William. �Contracting Out, One Way To Shrink Government Employment.� Nation�s Business (December 1977): 39-42.
Lauth, Thomas P. �Zero-Base Budgeting in Georgia State Government: Myth and Reality.� Public Administration Review (September/October 1978): 420-28.
�Lilly Digest Data for N.Y.� New York State Pharmacist (December 1979): 14.
�Lilly Digest Data for U.S.� New York State Pharmacist (December 1979): 16-17.
�The Lilly Digest: A Preview of Community Pharmacy-1975.� New York State Pharmacist (June 1976): 24-26.
�Lilly Digest: Profits at all-time low.� Apharmacy Weekly, vol. 18, no. 45 (November 14, 1979): 178.
�Lilly Digest�s Survey.� New York State Pharmacist (December 1978): 26.
Lindblom, Charles E. �The Science of �Muddling Through.�� Public Administration Review 19 (Spring 1959): 78-88.
. �Still Muddling, Not Yet Through.� Public Administration Review (November/December 1979): 517-26.
Meyer, Marvin C.; Bates, Herbert, Jr.; and Swift, Robert G. �The Role of State Formularies.� Journal of the American Pharmaceutical Association, vol. n.s. 14, no. 12 (December 1974): 663-66.
�Preview of 1979 Lilly Hospital Pharmacy Survey.� New York State Pharmacist (May 1980): 8.
�Rx Prices and Sizes Increase.� New York State Pharmacist (June 1977): 9.
Smith, Harry A. �Inflation Gauge: Measuring Growth in the Pharmacy.� American Pharmacy, vol. n.s. 20, no. 5 (May 1980): 50-51.
Smith, Mickey C., and Garner, Dewey D. �Effects of a Medicaid Program on Prescription Drug Availability and Acquisition.� Medical Care 12 (July 1974): 571-81.
�Timely Payment Regs on Medicaid Claims Do Apply to Pharmacists.� Apharmacy Weekly, vol. 18, no. 33 (August 15, 1979): 129.
�Why Soaring Public Worker Pensions Threaten You.� Nation�s Business (November 1976): 66-70.

Public Documents

�Annual Pharmacy Report for 1976.� Suffolk County Government Print Shop, 1977.
�Annual Pharmacy Report for 1979.� Suffolk County Government Print Shop, 1980.
�County of Suffolk New York Adopted Budget 1976.� Suffolk County Government Print Shop, 1976.
�County of Suffolk New York Adopted Budget 1977.� Suffolk County Government Print Shop, 1977.
�County of Suffolk New York Adopted Budget 1979.� Suffolk County Government Print Shop, 1979.
�County of Suffolk New York Tentative Budget 1978: Volume I: Summary.� Suffolk County Government Print Shop, 1978.
�County of Suffolk New York Tentative Budget 1980: Volume I: Summary.� Suffolk County Government Print Shop, 1980.
New York State. Chapter 77 of the Laws of 1977, 10 NYCRR 85.25.
New York State Education Law (1977). Title VIII, Article 137, Section 6816.
�Suffolk County Department of Social Services 1974 Annual Report.� Suffolk County Government Print Shop, 1975.
�Suffolk County Department of Social Services 1975 Annual Report.� Suffolk County Government Print Shop, 1976.
�Suffolk County Department of Social Services 1976 Annual Report.� Suffolk County Government Print Shop, 1977.
Suffolk County. Legislature. Committee on Legislative Finance. A Resolution for a Formulary Plan for Pharmaceutical Services within the Suffolk County Medicaid Program. Suffolk County Government Print Shop, 1977.

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